GW1-2021-07248_Well Construction - GW1_20211006

L U U IV O I M U U 1 I U IV M t U U t1 U (ta VV-I 1 For Intemal Use Only:
1.Well ntractor Informat' �+°����
�J`is 4
J. 14.WATER-ZONES
Well Conlra#Name FROM I TO DESCRIPTION
12�,C ft- 3 ft.
�J !J f ,
¢ Qr�tQJ :on �1 ft. (4�ft.
NC We Contractor Certification Number OUTER CASING for multi cased w Its DR LINER if a "licable
FROM TO DIAMETER THICKNESS MATERIAL
GCDsio&J Gc�Fu �. Tic, fY
ft. ft. G in. I 14,,ree'
Company Name
n� l / 00'
/ 6:1NNfR CASING-OR TUBING;. eoihermal'closed-loo `
2.Well Construction Permit#: �wJ P 0/ v FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e.U/C,County,State, Variance,etc.) ft. ft In.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DM 'cipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) _;Residential Water Supply(single) ft. ft. in.
IndustriaUCommercial rlResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO ER AL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. p* ft. UT
- Monitoring DRecovery ft. ft.
Injection Well:
Aquifer Recharge DGroundwaterRemediation Ab
19.SAND/GRAVEL PAC S appIicabi
ey
_Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling R FROM TO DESCRIPTION color,hardnm,soiVrock rain size,etc.
etum � Other(explain under#21 Remarks
It ft.
4.Date Well(s)Completed: Well I D# ft• Yo ft- $/. to O
5a.Well Location: v ft. 6';� ft. G-tf a h,�
G 3 ft- ft. /G► .
acility/Owner Name � Facility (if applicable) ft. ft.
5Sr` e Physical Address,City, d Zip ft. ft.
�_ -I l� Ci07 6 21.REMARKS '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certl ' tion:
W
6.Is(are)the wells) ermanent or []Temporary / Si fCertified Well Contractor Date
�j/ By si ning this form,l hereby certify that the well(s)was(were)constructed/n accordance
7.Is this a repair to an existing well: Dyes Or Q 0 with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
ff this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provfded,to the well owner.
repair underA21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1�W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 405 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells listall depths/f different(exampl 3@200'and 2@100)
construction to the following:
10.Static water level below top of casing: 7(�s (ft.) Division of Water Resources,Information Processing Unit,
Ifwa ter levelisabove casing,use^+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
above. also submit one copy ofthis form within 30 days of completion of well
12.Well construction method: s r 1 I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: t 1636 Mail Service Center,Raleigh,NG 27699-1636
I/
13a.Yield(gpm) Method of test: ` 24c. For Water Supply & Iniec tion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14. / Amount: completion of well constructionjto the county health department of the county
where constructed.